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CARRIER 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA PICA MEDICARE MEDICAID (Medicare #) TRICARE CHAMPUS (Sponsor’s SSN) (Medicaid #) GROUP HEALTH

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Maryland CHAMPUS YY INSUREDS NPI FECA USC SSN CFR seq coinsurance republished OWCP NUCC OMB 1990 false CMS CHAMPVA Feb 1988 EMG CMS-1500 TRICARE LMP ESA-30 24E nonphysicians ESA-12 17b nonmedical

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